• Medicare Part D

• AmeriHealth 65

• AmeriHealth Rx (NJ)

• AmeriHealth Rx (PA/WV)

• AmeriHealth Advantage (PA/WV)

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• Group Plans

• Disclaimers

AmeriHealth 65^®

Policies and forms

Policies

Privacy Practices
Your right to the privacy of your medical records and personal health information.

Your Rights and Responsibilities

For more information see section 3 of the Evidence of Coverage for the following plans.

AmeriHealth 65 NJ Value and Preferred — Medical Only

AmeriHealth 65 NJ Value and Preferred — Medical Plus Prescription Drug

AmeriHealth 65 NJ Plus — Medical Only

AmeriHealth 65 NJ Plus — Medicare Plus Prescription Drug

AmeriHealth 65 Eligibility Requirements
Find out if you are eligible to enroll in an AmeriHealth 65 Medicare plan.

Disenrollment

Leaving AmeriHealth 65 and your choices for continuing Medicare after you leave. For more information see section 6 of the Evidence of Coverage.

AmeriHealth 65 NJ Value and Preferred — Medical Only

AmeriHealth 65 NJ Value and Preferred — Medical Plus Prescription Drug

AmeriHealth 65 NJ Plus — Medical Only

AmeriHealth 65 NJ Plus — Medicare Plus Prescription Drug

Formulary Changes
Can your prescription drug formulary list change during the year?

Filling Prescriptions Outside the Network
Rules about filling a prescription when you are outside the network.

Forms

Authorization to Release Information
This form is used to release your Protected Health Information (PHI) as required by federal and state privacy laws.

Personal Representative Request Form
This form identifies the person who has legal authority to act on a member’s behalf in making decisions related to the member’s health care.